Why is implant reconstruction usually not recommended after radiation therapy?

Why do a lat flap and not just implants? Can radiated skin/area not “hold up” the implants? I'm going with a C cup so I'm really confused. I have lots more questions to ask my plastic surgeon. Just thought I'd try another opinion. I was now told she wants to do the lat flap on my right and implant on my left. Not happy about going through that surgery if I don't have to. Thank you.

Answer:

Thank you for your question… I’ll start out by stating that, BY FAR, the most important factor determining outcomes in implant-based breast reconstruction is quality of the mastectomy and, thus, quality of the post-mastectomy skin. ANY implant placed in the human body — from joint replacements to breast implants — is only as good as the tissue and skin that covers it.
With respect to implant breast reconstruction, the implants are separated from the outside world by a very thin layer of breast skin. Post-mastectomy skin is always “stressed out” to some degree as its primary source of blood flow — your breast tissue — is removed and, thus, requires the small vessels and capillaries under your skin to survive.

Even in the highest-quality mastectomies, other variables, such as:

prior or impending radiation

quality of the breast skin (amount of stretch marks)

size of the breast

prior surgery

amount of ptosis, or “sagging”

other medical issues (diabetes, smoking)

play a tremendous role in determining the ultimate ability of the breast skin to support an implant both in the near- and long-term.

With that being said, and specific to your question, the relationship between radiated skin and breast implants is rocky at best. Permanent, progressive, and irreversible stress is being added to already stressed skin. Further, capsular contracture of varying degrees of severity is the norm with implants in a radiated field.

Based on your surgeon's recommendation, it sounds as if she is anticipating a thinner skin envelope on the side with the cancer and/or is anticipating radiation therapy post-operatively. In this situation, the addition of additional vascularized tissue, such as a latissimus flap, is used to better protect and completely cover the implant. While implants are usually placed underneath the pectoralis muscle, it is not complete coverage. At most, two-thirds of the implant is covered by the pectoralis and, more often than not, over time there is retraction or “window shading” of the pectoralis over the implant and often leaves only one-third of the implant covered in the long-term.

The latissimus flap is a very common flap performed in this setting. It is safe, technically easy to perform with high success rate, and has a relatively straightforward recovery. The major drawback is that the operation involves sacrifice of a large trunk muscle and increases the animation deformity (when you move or strain, the breast will distort significantly until muscles are at complete rest) due to action of both the pectoralis and latissimus over the implant. The donor sites can also be difficult, as risk of a seroma — fluid collection — at the donor site is high and there is obvious difference in appearance of the back on the side with latissimus versus the side where the latissimus flap was taken from. Further, the degree to which losing the normal function of the latissimus muscle affects daily life is controversial and is often individual-dependent based upon line of work and hobbies, but is a legitimate concern.

Taking all of this into consideration, while I agree that likely adding your own tissue is necessary in your situation and reduces risk of implant-related complication, there are other reliable options that do not involve sacrifice of muscle and have more favorable donor sites such as the DIEP, SGAP, and TUG flaps. These options involve microsurgical transfer of fat from areas of natural excess, while sparing muscle. While these options may have slightly longer recoveries, the trade-off is permanence. The DIEP flap, for example, is regarded as the “gold standard” for tissue restoration of the breast. Outcomes relative to these options are optimized in centers that perform large volumes of microsurgical procedures using organized and experienced teams and, thus, it is not uncommon for people to travel for these procedures. It’s worth learning about these options as they are frequently used in situations where there is dissatisfaction with implant-based results, or failed implant reconstructions due to exposure, severe capsular contracture, or need for many revisions over time.

In any case, I commend you for sharing your concerns and advocating for yourself regarding these complex issues. You should be informed of ALL options available to you in an environment where questions are welcomed and shared decision-making between you and your surgeon is valued. I encourage you to seek more than one opinion and wish you all the best.

— Chris Trahan, M.D., F.A.C.S.

Chris Trahan, M.D., F.A.C.S.

Dr. Trahan is part of the reconstruction team at the Center for Restorative Breast Surgery in New Orleans, Louisiana. Learn more about Dr. Trahan.